The Scottish doctor--learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners

Evaluating competency-based medical education: a systematized review of current practices

BACKGROUND

Few published articles provide a comprehensive overview of the available evidence on the topic of evaluating competency-based medical education (CBME) curricula. The purpose of this review is therefore to synthesize the available evidence on the evaluation practices for competency-based curricula employed in schools and programs for undergraduate and postgraduate health professionals.

METHOD

This systematized review was conducted following the systematic reviews approach with minor modifications to synthesize the findings of published studies that examined the evaluation of CBME undergraduate and postgraduate programs for health professionals.

RESULTS

Thirty-eight articles met the inclusion criteria and reported evaluation practices in CBME curricula from various countries and regions worldwide, such as Canada, China, Turkey, and West Africa. 57% of the evaluated programs were at the postgraduate level, and 71% were in the field of medicine. The results revealed variation in reporting evaluation practices, with numerous studies failing to clarify evaluations' objectives, approaches, tools, and standards as well as how evaluations were reported and communicated. It was noted that questionnaires were the primary tool employed for evaluating programs, often combined with interviews or focus groups. Furthermore, the utilized evaluation standards considered the well-known competencies framework, specialized association guidelines, and accreditation criteria.

CONCLUSION

This review calls attention to the importance of ensuring that reports of evaluation experiences include certain essential elements of evaluation to better inform theory and practice.

The identification of requirements for competency development during work-integrated learning in healthcare education

BACKGROUND

Work-integrated learning (WIL) is widely accepted and necessary to attain the essential competencies healthcare students need at their future workplaces. Yet, competency-based education (CBE) remains complex. There often is a focus on daily practice during WIL. Hereby, continuous competency development is at stake. Moreover, the fact that competencies need to continuously develop is often neglected.

OBJECTIVES

To ultimately contribute to the optimization of CBE in healthcare education, this study aimed at examining how competency development during WIL in healthcare education could be optimized, before and after graduation.

METHODS

Fourteen semi-structured interviews with 16 experts in competency development and WIL were carried out. Eight healthcare disciplines were included namely associate degree nursing, audiology, family medicine, nursing (bachelor), occupational therapy, podiatry, pediatrics, and speech therapy. Moreover, two independent experts outside the healthcare domain were included to broaden the perspectives on competency development. A qualitative research approach was used based on an inductive thematic analysis using Nvivo12© where 'in vivo' codes were clustered as sub-themes and themes.

RESULTS

The analysis revealed eight types of requirements for effective and continuous competency development, namely requirements in the context of (1) competency frameworks, (2) reflection and feedback, (3) assessment, (4) the continuity of competency development, (5) mentor involvement, (6) ePortfolios, (7) competency development visualizations, and (8) competency development after graduation. It was noteworthy that certain requirements were fulfilled in one educational program whereas they were absent in another. This emphasizes the large differences in how competence-based education is taking shape in different educational programs and internship contexts. Nevertheless, all educational programs seemed to recognize the importance of ongoing competency development.

CONCLUSION

The results of this study indicate that identifying and meeting the requirements for effective and continuous competency development is essential to optimize competency development during practice in healthcare education.

Patient Perceptions of Medical Students' Involvement in Clinical Classes: A Cross-Sectional Survey

Introduction

A crucial aspect of the education of prospective medical professionals is their interaction with patients. The study aimed to explore patients' perspectives on the interaction between medical students and themselves. It sought to understand how patients perceive this dynamic within clinical classes. The goal was to gather insights into the most favorable behavior and demeanor of medical students during these sessions, with the overarching objective of enhancing patient comfort.

Material and Methods

The authors collected a total of 403 surveys from patients of a teaching hospital, regarding their perception of students as healthcare providers. The participants ranged in age from 18 to 92. 53.83% of the participants were female, and 46.17% were male. The surveys were collected between April 8th, 2022, and August 10th, 2022. The results of the anonymous survey undergone statistical analyses using the Mann‒Whitney U-test for comparing two groups and the Kruskal‒Wallis test for comparing more than two groups, because the Shapiro‒Wilk test indicated that the data did not follow a normal distribution.

Results

The study delved into patients' assessments of students' external presentation, adherence to behavioral norms, empathetic qualities, consideration during intimate examinations, and preferences for the organization of clinical classes. Our research indicates notable differences in responses based on age. Specifically, the senior demographic prioritizes students' external presentation, communication and the utilization of courteous language more often than younger individuals (p<0.05). Attendees exhibit varying levels of interest in participating in educational sessions with students based on the ward. Significantly, individuals in the gynecology ward display the least enthusiasm for engagement (p<0.05). Notably, the majority of patients perceive their involvement in the education of future healthcare professionals to be essential (83.38%).

Conclusion

The study found that generally, patients voluntarily engage in educational classes with students. The relationship between patients and students is amicable, and the majority of students display a respectful demeanor toward patients. Nonetheless, preserving patient confidentiality and ensuring the proper management of classes remain persistent issues. This is particularly crucial, especially when the clinical classes pertain to intimate and personal health matters of a patient. Upholding and enriching the organization of such sessions, along with the attentiveness and knowledge of medical students regarding patient comfort, assumes heightened significance.

The impact of emotionally challenging situations on medical students' professional identity formation

In their interactions with patients and health care professionals during work-based learning, medical students are known to experience emotionally challenging situations that can evoke negative feelings. Students have to manage these emotions. Students learn and develop their professional identity formation through interactions with patients and members of the healthcare teams. Earlier studies have highlighted the issues involved with processing emotionally challenging situations, although studies concerning learning and professional identity formation in response to these experiences are rare. In this study, we explored medical students' experiences of emotionally challenging situations in work-based learning, and the impact these experiences had on forming medical students' professional identities. We conducted an analysis of narrative data (n = 85), using a constructivist grounded theory approach. The narratives were made up of medical students' reflective essays at the end of their education (tenth term). The analysis showed that students' main concern when facing emotionally challenging situations during their work-based education was the struggle to achieve and maintain a professional approach. They reported different strategies for managing their feelings and how these strategies led to diverse consequences. In the process, students also described arriving at insights into their own personal needs and shortcomings. We consider this development of self-awareness and resulting self-knowledge to be an important part of the continuously ongoing socialization process of forming a professional identity. Thus, experiencing emotionally challenging situations can be considered a unique and invaluable opportunity, as well as a catalyst for students' development. We believe that highlighting the impact of emotions in medical education can constitute an important contribution to knowledge about the process of professional identity formation. This knowledge can enable faculty to provide students with more effective and sufficient support, facilitating their journey in becoming physicians.

Investigating the advantages and disadvantages of electronic logbooks for education goals promotion in medical sciences students: A systematic review

Background and Aims

Electronic logbook (E-Logbook) is one of the practical software in medical science that serves as an auxiliary tool for comprehensive education, formative evaluation, and student learning documentation in clinical education. E-logbooks are available to people on the Internet without any time or place restrictions. Experts' familiarity with e-logbooks and their advantages and disadvantages can be effective in their better design so professors and students can use their potential benefits. Therefore, this study examines the advantages and disadvantages of an e-logbook.

Methods

This systematic review was conducted until June 13, 2022, by searching relevant keywords such as logbook, e-logbook, and medical students in PubMed, Scopus, and Web of Science databases. Data were extracted using the data extraction form. The contents of the studies were analyzed based on the study's aim. The results of the analyses were presented in the form of descriptive statistics (tables and figures).

Results

Out of 365 retrieved studies, 13 were selected to investigate the advantages and disadvantages of e-logbooks. Most studies were conducted in Pakistan (n = 4) and focused on medical students with different specialties (n = 10). The advantages and disadvantages of e-logbooks were classified into nine and four categories, respectively. Most advantages of e-logbooks were related to monitoring and evaluating the performance of students and instructors (n = 11). Their most disadvantages were associated with hardware and software (n = 8).

Conclusion

According to the results, e-logbooks can improve clinical education, provide feedback to people, control the achievement of educational goals, and increase professor-student interaction. Hence, it is recommended to address their disadvantages and barriers to improve the quality of students' performance.

Assessment of professional identity formation: a transcultural validation of the professional identity essay for brazilian portuguese

INTRODUCTION

Professional identity formation (PIF) is recognized worldwide as an outcome of medical education grounded in the psychology of adult development and the literature on medical professionalism. However, instruments to assess and support PIF are scarce. The Professional Identity Essay (PIE) is an open-ended question assessment of PIF that elicits short narrative responses from learners and that can be analyzed to provide formative feedback and an overall stage of development. In this study, our aim was to translate and adapt the PIE to Brazilian Portuguese.

METHODS

We followed a systematic procedure for the translation and cross-cultural adaptation of the instrument. A pilot study was conducted with medical students from the University of São Paulo. After providing individual formative feedback, we administered an online questionnaire to the Brazilian students to better understand the consequences of using the PIE. Content analyses of qualitative data were performed, we employ manifest content analysis, and the categories of analysis emerged from the participants' speeches.

RESULTS

Students found the instrument's questions easy to interpret and self-reflective. It also gave students the opportunity to consider their PIF. The PIE was perceived as reliable and brought more awareness of the students' own processes in addition to a sense of capability to foster their own development. In the same way, the students emphasized the importance of being helped in this process.

CONCLUSION

We found sufficient evidence of the validity of the PIE in terms of content, face validity, and consequences of use. The PIE enhances self-assurance in PIF through formative assessment and is sensitive to different cultures, making it a potential tool for educators.

Data Analysis of Physician Competence Research Trend: Social Network Analysis and Topic Modeling Approach

BACKGROUND

Studies on competency in medical education often explore the acquisition, performance, and evaluation of particular skills, knowledge, or behaviors that constitute physician competency. As physician competency reflects social demands according to changes in the medical environment, analyzing the research trends of physician competency by period is necessary to derive major research topics for future studies. Therefore, a more macroscopic method is required to analyze the core competencies of physicians in this era.

OBJECTIVE

This study aimed to analyze research trends related to physicians' competency in reflecting social needs according to changes in the medical environment.

METHODS

We used topic modeling to identify potential research topics by analyzing data from studies related to physician competency published between 2011 and 2020. We preprocessed 1354 articles and extracted 272 keywords.

RESULTS

The terms that appeared most frequently in the research related to physician competency since 2010 were knowledge, hospital, family, job, guidelines, management, and communication. The terms that appeared in most studies were education, model, knowledge, and hospital. Topic modeling revealed that the main topics about physician competency included Evidence-based clinical practice, Community-based healthcare, Patient care, Career and self-management, Continuous professional development, and Communication and cooperation. We divided the studies into 4 periods (2011-2013, 2014-2016, 2017-2019, and 2020-2021) and performed a linear regression analysis. The results showed a change in topics by period. The hot topics that have shown increased interest among scholars over time include Community-based healthcare, Career and self-management, and Continuous professional development.

CONCLUSIONS

On the basis of the analysis of research trends, it is predicted that physician professionalism and community-based medicine will continue to be studied in future studies on physician competency.

When theory beats practice: the implementation of competency-based education at healthcare workplaces : Focus group interviews with students, mentors, and educators of six healthcare disciplines

BACKGROUND

Work-integrated learning constitutes a large part of current healthcare education. During the last decades, a competency-based educational (CBE) approach has been introduced to reduce the theory-practice gap and to promote continuous competency development. Different frameworks and models have been developed to support CBE implementation in practice. Although CBE is now well-established, implementation at healthcare workplaces remains complex and controversial. This study aims to explore how students, mentors, and educators from different healthcare disciplines perceive the implementation of CBE at the workplace. The six-step model of Embo et al. (2015) was used as a base: (1) competency selection, (2) formulating learning goals, (3) self-monitoring performance, (4) self-assessing competency development, (5) summative assessment of individual competencies, and (6) summative assessment of global professional competence.

METHODS

Three semi-structured focus group interviews were conducted with (1) five students, (2) five mentors, and (3) five educators. We recruited participants from six different educational programs: audiology, midwifery, nursing (associate degree and bachelor), occupational therapy, or speech therapy. We used thematic analysis combining an inductive and deductive approach.

RESULTS

An overview of the predefined competencies was hard to find which complicated CBE implementation and resulted in a lack of consistency between the steps; e.g., the link between the selection of relevant competencies (step 1) and the formulation of learning goals based on these selected competencies (step 2) was absent. Furthermore, the analysis of the data helped identifying seven barriers for CBE implementation: (1) a gap between the educational program and the workplace, (2) a lacking overview of predefined competencies, (3) a major focus on technical competencies at the expense of generic competencies, (4) weak formulation of the learning goals, (5) obstacles related to reflection, (6) low feedback quality, and (7) perceived subjectivity of the assessment approach.

CONCLUSION

The present barriers to CBE implementation lead to a fragmentation of current work-integrated learning. In this way, theory beats practice when it comes to CBE implementation as the theory of CBE is not effectively implemented. However, the identification of these barriers might help to find solutions to optimize CBE implementation. Future research seems critical to optimize CBE so that theory can meet practice and the opportunities of CBE optimize healthcare education.

A framework for residents' pursuit of excellence based upon non-cognitive and cognitive attributes

PURPOSE

Excellence, although variably conceptualized, is commonly used in medicine and the resident excellence literature is limited. Both cognitive attributes (CAs) and non-cognitive attributes (NCAs) are essential for academic and clinical performance; however, the latter are difficult to evaluate. Undergirded by an inclusive and non-competitive approach and utilizing CAs and NCAs, we propose a criterion-referenced behavioral framework of resident excellence.

METHODS

Perceptions of multiple stakeholders (educational administrators, faculty, and residents), gathered by survey (n = 218), document analysis (n = 52), and focus group (n = 23), were analyzed. Inductive thematic analysis was followed by deductive interpretation and categorization using sensitizing concepts for excellence, NCAs, and CAs. Chi-squared tests were used to determine stakeholder perception differences.

RESULTS

All stakeholders had similar perceptions (P > .05) and 13 behavioral attributes in 6 themes undergirded by insight and conscientiousness were identified. The NCAs included: interpersonal skills (works with others, available, humble), professional (compassionate, trustworthy), commitment to profession (visible, volunteers), commitment to learn (proactively seeks feedback, creates learning opportunities), and work-life balance/integration (calm demeanor, inspirational). The CA (medical knowledge and intellect) included: applies knowledge to gain expertise and improves program's caliber.

CONCLUSION

Resident excellence is posited as a pursuit. The attributes are non-competitive, inclusionary, potentially achievable by all, and do not negatively affect freedom of choice. However, contextual and cultural differences are likely and these need validation across societal equity segments. There are implications for learners (adaptive reflection and learning goal orientation), faculty (reduced bias and whole-person feedback), and system leaders (enhancing culture and learning environments) to foster excellence.

Competency-Based Medical Education (CBME): an Overview and Relevance to the Education of Future Surgical Oncologists

In the next two decades, the global cancer burden is expected to rise by 47%, and the demand for global cancer surgery will increase by 52%. At present, only 25% of the estimated 80% of patients needing surgical intervention have access to timely surgical care. The shortage of a trained workforce of surgical oncologists is one of the main barriers to providing the optimal surgical intervention needed for cancer patients. Some of the contributing factors to the shortage of trained surgical oncologists are variations in the current global educational platforms, long training programs, and physician burnout. Therefore, the availability of a credible training framework and a sustainable certification pipeline for future surgical oncologists is critical to meet the global demand for an adequate healthcare workforce. The current surgical oncology educational program is a time-based construct that trains surgeons to function seamlessly in the multidisciplinary care of cancer patients. However, there is a lack of flexibility in the training framework and timeline despite differences in trainees' abilities. Developing a globally acceptable standard curriculum for surgical oncology training based on the competency-based medical education (CBME) framework and tailoring it to local needs can increase the surgical oncology workforce ready to tackle the rising cancer burden. However, successful implementation of the global CBME-based surgical oncology training curriculum requires an innovative approach to ensure that this framework produces a competent surgical oncologist that meets the local needs.

Fostering uncertainty tolerance in anatomy education: Lessons learned from how humanities, arts and social science (HASS) educators develop learners' uncertainty tolerance

Uncertainty tolerance, individuals' perceptions/responses to uncertain stimuli, is increasingly recognized as critical to effective healthcare practice. While the Covid-19 pandemic generated collective uncertainty, healthcare-related uncertainty is omnipresent. Correspondingly, there is increasing focus on uncertainty tolerance as a health professional graduate "competency," and a concomitant interest in identifying pedagogy fostering learners' uncertainty tolerance. Despite these calls, practical guidelines for educators are lacking. There is some initial evidence that anatomy education can foster medical students' uncertainty tolerance (e.g., anatomical variation and dissection novelty), however, there remains a knowledge gap regarding robust curriculum-wide uncertainty tolerance teaching strategies. Drawing upon humanities, arts and social sciences (HASS) educators' established uncertainty tolerance pedagogies, this study sought to learn from HASS academics' experiences with, and teaching practices related to, uncertainty pedagogy using a qualitative, exploratory study design. Framework analysis was undertaken using an abductive approach, wherein researchers oscillate between inductive and deductive coding (comparing to the uncertainty tolerance conceptual model). During this analysis, the authors analyzed ~386 min of data from purposively sampled HASS academics' (n = 14) discussions to address the following research questions: (1) What teaching practices do HASS academics' perceive as impacting learners' uncertainty tolerance, and (2) How do HASS academics execute these teaching practices? The results extend current understanding of the moderating effects of education on uncertainty tolerance and supports prior findings that the anatomy learning environment is ripe for supporting learner uncertainty tolerance development. This study adds to growing literature on the powerful moderating effect education has on uncertainty tolerance and proposes translation of HASS uncertainty tolerance teaching practices to enhance anatomy education.

Competencies required for graduated physicians: the integration of Englander's common taxonomy in a validated scale for the assessment of competency acquiring in undergraduate medical education

BACKGROUND

Competency-based medical education has been emerging as a new educational model for learning. The development of medical education in Middle Eastern countries lacks basic literature in the area of medical education, particularly competency-based medical education (CBME).

AIM

Our objective is to validate a brief/rapid scale that informs us on the current perception of the acquiring of competencies of medical students and graduates from the Lebanese University, Lebanon.

METHODS

A survey containing the Englander's common taxonomy for medical competencies-a set of 57 items-was distributed to medical students and graduates from the Lebanese University. Three parameters were used for the validation of this scale: construct validity using the principal component analysis technique, internal reliability using Cronbach alpha, and convergent validity using Pearson correlation.

RESULTS

A total of 377 participants responded to the survey. Factor analysis, using Varimax rotation, showed appropriate loading of domains; loadings varied between 0.648 and 0.899. Construct validity showed for all competencies loaded appropriately in their respective domains; loadings ranged between 0.656 and 0.913. Cronbach alpha values were very good to excellent (0.868 to 0.932). Pearson correlation coefficients showed a good correlation with the total score and varied between 0.739 and 0.893 (p < 0.0001).

CONCLUSION

The Englander's common taxonomy scale is valid and reliable among Lebanese medical students and could be used for concise assessment of current and past medical education in faculties among Lebanese medical students. Using such scales can be used in assessing the improvement of medical education towards CBME.

Developing and Mapping Entrustable Professional Activities with Saudi Meds Competency Framework: A Consensus Study

PURPOSE

This study aimed at developing a national consensus on entrustable professional activities (EPAs) for Saudi undergraduate medical education and mapping them with the "Saudi Meds" competency framework.

METHODS

A three phased approach was used. Phase 1 consisted of identifying and developing EPAs; Phase 2 consisted of building a national consensus on developed EPAs (validation process); and Phase 3 consisted of mapping the validated EPAs with the Saudi Meds competency framework. Nominal group and modified Delphi techniques were used to develop consensus on EPAs. Classical test theory-based item analysis was conducted to establish validity and reliability of finalized EPAs.

RESULTS

Fifteen expert medical educationists and 109 academic leaders from 23 medical schools participated in the validation process. The study achieved a consensus on 10 core EPAs with an overall reliability (Cronbach's Alpha) of 0.814. The item-total correlation ranged from 0.341 to 0.642.

CONCLUSION

This study results in a national consensus on generic, comprehensive and region-specific EPAs that have been mapped with Saudi Meds competency framework. Our study is the first step in the direction of facilitating EPA-based curricular reforms in Saudi medical schools.

Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience

IMPORTANCE

Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience.

OBJECTIVE

To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience.

DESIGN, SETTING, AND PARTICIPANTS

This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021.

MAIN OUTCOMES AND MEASURES

The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities.

RESULTS

Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits.

CONCLUSIONS AND RELEVANCE

In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.

Teaching Medical Students to Teach: A Narrative Review and Literature-Informed Recommendations for Student-as-Teacher Curricula

PURPOSE

Medical students play an important role as teachers. This narrative review synthesizes the student-as-teacher (SaT) literature that incorporates formal teaching skills training, with the goal of proposing literature-informed recommendations for SaT curriculum development within the context of competency-based medical education.

METHOD

In January and August 2020, the authors searched Medline and Embase and conducted forward citation searches in Scopus to identify articles from 1985 to 2020 related to teaching medical students to teach. Search terms included "student(s) as teacher(s)," "near-peer teaching," and "teaching to teach." The findings from selected articles were summarized and synthesized.

RESULTS

Forty-three articles met the inclusion criteria: 33 papers describing specific SaT curricula, 3 literature reviews, 6 stakeholder surveys, and 1 Delphi study. While students often engage in teaching roles, formal teaching skills training is not always provided. Existing curricula are usually optional, delivered as short courses, and offered to senior students. Course content commonly includes topics related to planning and delivering learning activities and providing feedback. Of the numerous teaching modalities employed, students indicate a preference for interactive and experiential learning. Methods used to assess students' teaching skills vary; however, direct observation and feedback are valued assessment methods. Program evaluations have shown positive outcomes, including high student satisfaction and enhanced self-confidence as teachers.

CONCLUSIONS

Informed by these findings and outcome-based educational frameworks, the authors suggest 4 guiding principles for SaT curricula: (1) teaching skills training should be formally implemented in undergraduate medical education and should, whenever possible, be compulsory; (2) teaching skills should be taught longitudinally and progressively along the undergraduate to postgraduate continuum; (3) curriculum content should be aligned with a school's preexisting curriculum and local context; and (4) authentic opportunities for students to engage in teaching roles should be included. They also propose recommendations for curriculum content, teaching modalities, and assessment methods.

Factors Associated with Physician Tolerance of Uncertainty: an Observational Study

BACKGROUND

Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area.

OBJECTIVE

To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout.

DESIGN

Online confidential survey.

SETTING

The Massachusetts General Physicians Organization (MGPO).

PARTICIPANTS

All 2172 clinically active faculty in the MGPO.

MAIN MEASURES

We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics.

KEY RESULTS

Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90).

CONCLUSION

At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.

An online Delphi study to investigate the completeness of the CanMEDS Roles and the relevance, formulation, and measurability of their key competencies within eight healthcare disciplines in Flanders

BACKGROUND

Several competency frameworks are being developed to support competency-based education (CBE). In medical education, extensive literature exists about validated competency frameworks for example, the CanMEDS competency framework. In contrast, comparable literature is limited in nursing, midwifery, and allied health disciplines. Therefore, this study aims to investigate (1) the completeness of the CanMEDS Roles, and (2) the relevance, formulation, and measurability of the CanMEDS key competencies in nursing, midwifery, and allied health disciplines. If the competency framework is validated in different educational programs, opportunities to support CBE and interprofessional education/collaboration can be created.

METHODS

A three-round online Delphi study was conducted with respectively 42, 37, and 35 experts rating the Roles (n = 7) and key competencies (n = 27). These experts came from non-university healthcare disciplines in Flanders (Belgium): audiology, dental hygiene, midwifery, nursing, occupational therapy, podiatry, and speech therapy. Experts answered with yes/no (Roles) or on a Likert-type scale (key competencies). Agreement percentages were analyzed quantitatively whereby consensus was attained when 70% or more of the experts scored positively. In round one, experts could also add remarks which were qualitatively analyzed using inductive content analysis.

RESULTS

After round one, there was consensus about the completeness of all the Roles, the relevance of 25, the formulation of 24, and the measurability of eight key competencies. Afterwards, key competencies were clarified or modified based on experts' remarks by adding context-specific information and acknowledging the developmental aspect of key competencies. After round two, no additional key competencies were validated for the relevance criterion, two additional key competencies were validated for the formulation criterion, and 16 additional key competencies were validated for the measurability criterion. After adding enabling competencies in round three, consensus was reached about the measurability of one additional key competency resulting in the validation of the complete CanMEDS competency framework except for the measurability of two key competencies.

CONCLUSIONS

The CanMEDS competency framework can be seen as a grounding for competency-based healthcare education. Future research could build on the findings and focus on validating the enabling competencies in nursing, midwifery, and allied health disciplines possibly improving the measurability of key competencies.

Rheumatology Milestones 2.0: A Roadmap for Competency-Based Medical Training of Rheumatology Fellows in the 21st Century

OBJECTIVE

Since 2014, rheumatology fellows have been assessed not only based on their ability to provide patient care and possession of medical knowledge but also on their skill in serving as patient advocates, navigators of health systems, and members of a health care team. Such assessments have been carried out through the use of competency-based milestones from the Accreditation Council of Graduate Medical Education (ACGME). However, a needs assessment has demonstrated interest in more context validity and subspecialty relevance since the development of the ACGME internal medicine (IM) subspecialty reporting milestones. The ACGME thus created a milestones working group, and the present study was undertaken to develop Rheumatology Milestones 2.0 as well as a supplemental guide to assist with implementation.

METHODS

The working group, consisting of 7 rheumatology program directors, 2 division directors, a community practice rheumatologist, a rheumatology fellow in training, and a public member who is a rheumatology patient, was overseen by the ACGME vice president for milestones development and met through three 12-hour, in-person meetings to compose the rheumatology specialty milestones and supplemental guide within the ACGME Milestones 2.0 project.

RESULTS

Informed by the needs assessment data and stakeholders, the working group revised and adapted the ACGME IM subspecialty reporting milestones to create a rheumatology-specific set of milestones and a supplemental guide for their implementation.

CONCLUSION

The Rheumatology Milestones 2.0 provides a specialty-specific, competency-based evaluation tool that can be used by program directors, clinical competency committees, and others to assess the competencies of rheumatology fellows during training and help measure readiness for independent practice.

The McMaster Advanced Communication Competencies Model for Psychiatry (MACC Model)

OBJECTIVE

Communication is a core competency for all physicians in training. In Canada, the importance of communication during residency is recognized through the CanMEDS framework. Although literature exists around teaching communication skills to residents, research in psychiatry residents is lacking. The purpose of this study was to explore how faculty members conceptualize the development of communication skills in psychiatry residents and develop a model reflecting this.

METHODS

The authors used a constructivist grounded theory approach. Purposive sampling was used to select 14 faculty educators who regularly supervise psychiatry residents in a single university-based residency training program. Semi-structured interviews were conducted to explore educators' perceptions of how communication skills develop during residency. Constant comparative analysis occurred concurrently with data collection until thematic theoretical sufficiency was reached and relationships between themes determined.

RESULTS

Five themes underlie the McMaster Advanced Communication Competencies model, describing the progressive development of communication abilities in residents. Three themes identify foundational sets of abilities including: refining common foundational relational abilities, developing foundational specific psychiatric communication abilities, and learning to reflect upon and manage internal reactions. These foundational pillars then allow residents to develop a personalized art of flexible psychiatric interviewing, and skillfully partner with patients in co-creating care plans.

CONCLUSIONS

This research describes a preliminary communication competency model for teaching and assessing psychiatry residents. It defines the core communication abilities required for residents to progress to independent practice. Future research could explore and test the model's validity and transferability.

Entrustable Professional Activities for Chinese Standardized Residency Training in Pediatric Intensive Care Medicine

BACKGROUND

Entrustable professional activities (EPAs) were first introduced by Olle ten Cate in 2005. Since then, hundreds of applications in medical research have been reported worldwide. However, few studies discuss the use of EPAs for residency training in pediatric intensive care medicine. We conducted a pilot study of EPA for pediatric intensive care medicine to evaluate the use of EPAs in this subspecialty.

MATERIALS AND METHODS

A cross-sectional study was implemented in pediatric intensive care medicine standardized residency training at the Qilu Hospital of Shandong University. An electronic survey assessing EPA performance using eight scales composed of 15 categories were distributed among residents and directors.

RESULTS

A total of 217 director-assessment and 44 residents' self-assessment questionnaires were collected, both demonstrating a rising trend in scores across postgraduate years. There were significant differences in PGY1-vs.-PGY2 and PGY1-vs.-PGY3 director-assessment scores, while there were no differences in PGY2-vs.-PGY3 scores. PGY had a significant effect on the score of each EPA, while position significantly affected the scores of all EPAs except for EPA1 (Admit a patient) and EPA2 (Select and interpret auxiliary examinations). Gender only significantly affected the scores of EPA6 (Report a case), EPA12 (Perform health education), and EPA13 (Inform bad news).

CONCLUSION

This study indicates that EPA assessments have a certain discriminating capability among different PGYs in Chinese standardized residency training in pediatric intensive care medicine. Postgraduate year, gender, and resident position affected EPA scores to a certain extent. Given the inconsistency between resident-assessed and director-assessed scores, an improved feedback program is needed in the future.

Development of an integrated competency framework for postgraduate paediatric training: a Delphi study

Competency-based education (CBE) has transformed medical training during the last decades. In Flanders (Belgium), multiple competency frameworks are being used concurrently guiding paediatric postgraduate CBE. This study aimed to merge these frameworks into an integrated competency framework for postgraduate paediatric training. In a first phase, these frameworks were scrutinized and merged into one using the Canadian Medical Education Directives for Specialists (CanMEDS) framework as a comprehensive basis. Thereafter, the resulting unified competency framework was validated using a Delphi study with three consecutive rounds. All competencies (n = 95) were scored as relevant in the first round, and twelve competencies were adjusted in the second round. After the third round, all competencies were validated for inclusion. Nevertheless, differences in the setting in which a paediatrician may work make it difficult to apply a general framework, as not all competencies are equally relevant, applicable, or suitable for evaluation in every clinical setting. These challenges call for a clear description of the competencies to guide curriculum planning, and to provide a fitting workplace context and learning opportunities.Conclusion: A competency framework for paediatric post-graduate training was developed by combining three existing frameworks, and was validated through a Delphi study. This competency framework can be used in setting the goals for workplace learning during paediatric training. What is Known: •Benefits of competency-based education and its underlying competency frameworks have been described in the literature. •A single and comprehensive competency framework can facilitate training, assessment, and certification. What is New: •Three existing frameworks were merged into one integrated framework for paediatric postgraduate education, which was then adjusted and approved by an expert panel. •Differences in the working environment might explain how relevant a competency is perceived.

Defining performance levels in undergraduate otolaryngology education

OBJECTIVES

This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology.

METHODS

A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors.

RESULTS

Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few.

CONCLUSION

This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

Development of a veterinary emergency open standard competency framework using a competency-based model of medical education

OBJECTIVE

To address the shortage of emergency veterinarians, the profession is exploring accelerated training pathways. We sought to contribute to the solution by developing the foundation for an open standard, competency-based veterinary emergency training curriculum for use by any program. We also developed a curricular delivery, tracking, and assessment system to demonstrate how the framework can be integrated into training programs.  DESIGN: Hybrid Delphi method.  SETTING: Academia and referral practice.  ANIMALS: None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

An emergency veterinary competency framework was developed by adapting the human Model of the Clinical Practice of Emergency Medicine, which aligns with the Competency-Based Veterinary Education framework, to produce 4 areas of core competency: Patient Care, Interpersonal/Communication, Professionalism, and Practice-based Learning/Improvement. A comprehensive list of veterinary emergency skills was generated and organized within the framework utilizing the hybrid Delphi method. An initial survey completed by 133 emergency and critical care specialists and emergency room clinicians produced data regarding the value of specific skills. An 11-member focus group consisting of survey participants iterated upon the survey results to produce a master library of skills and cases, including 56 Patient Care, 43 Interpersonal/Communication, 11 Practice-based Learning/Improvement, and 20 Professionalism skills, as well as 155 case types. The curricular delivery system tracks and assesses case management proficiency and development of knowledge and professional skills using a patient care eLearning program and simulation training environment.  CONCLUSIONS: The increasing need for emergency veterinarians is a shared industry-wide challenge. To contribute toward a collective solution, we have undergone an evidence-based process to create the foundation for an open standard competency framework composed of a library of skills and cases. We offer this open standard framework to the veterinary profession and hope it continues to grow and evolve as we drive toward developing competency-based training programs that address the shortage of emergency veterinarians.

Design, Implementation, and Evaluation of a Distance Learning Framework to Adapt to the Changing Landscape of Anatomy Instruction in Medical Education During COVID-19 Pandemic: A Proof-of-Concept Study

This study presents the design of a DL-framework to deliver anatomy teaching that provides a microfiche of the onsite anatomy learning experience during the mandated COVID-19 lockdown. First, using nominal-group technique, we identified the DL learning theories to be employed in blueprinting the DL-framework. Effectiveness of the designed DL-framework in anatomy teaching was demonstrated using the exemplar of the Head and Neck (H&N) course during COVID-19 lockdown, in the pre-clerkship curriculum at our medical school. The dissemination of the DL-framework in the anatomy course was informed by the Analyse, Design, Develop, Implement, and Evaluate (ADDIE) model. The efficiency of the DL-framework was evaluated using the first two levels of Kirkpatrick's model. Versatility of the DL-framework was demonstrated by aligning its precepts with individual domains of key learning outcomes framework. The framework's blueprint was designed amalgamating principles of: Garrison's community inquiry, Siemens' connectivism and Harasim's online-collaborative-learning; and improved using Anderson's DL-model. Following the implementation of the DL-framework in the H&N course informed by ADDIE, the framework's efficiency was evaluated. In total, 70% students responded to the survey assessing perception toward DL (Kirkpatrick's Level: 1). Descriptive analysis of the survey results showed that the DL-framework was positively received by students and attested that students had an enriched learning experience, which promoted collaborative-learning and student-autonomy. For, Kirkpatrick's Level: 2 i.e., cognitive development, we compared the summative assessment performance in the H&N course across three cohort of students. The results show that the scores of the cohort, which experienced the course entirely through DL modality was statistically higher (P < 0.01) than both the other cohorts, indicating that shift to DL did not have an adverse effect on students' learning. Using Bourdieu's Theory of Practice, we showed that the DL-framework is an efficient pedagogical approach, pertinent for medical schools to adopt; and is versatile as it attests to the key domains of students' learning outcomes in the different learning outcomes framework. To our knowledge this is the first-study of its kind where a rationale and theory-guided approach has been availed not only to blueprint a DL framework, but also to implement it in the MBBS curriculum.

Using the Five Core Components of Competency-Based Medical Education to Support Implementation of CBVE

In recent years, veterinary education has begun the transition to competency-based models, recognizing that, like medical education, our goals include improved patient and client outcomes and the importance of learner-centered methods in education. Given that implementation of competency-based veterinary education (CBVE) is still in its relative infancy across many veterinary programs, we stand to gain from a unified approach to its implementation. As a guideline, the five core components of competency-based medical education (CBME) should serve to ensure and maintain fidelity of the original design of outcomes-based education during implementation of CBVE. Identified the essential and indispensable elements of CBME which include 1) clearly articulated outcome competencies required for practice, 2) sequenced progression of competencies and their developmental markers, 3) tailored learning experiences that facilitate the acquisition of competencies, 4) competency-focused instruction that promotes the acquisition of competencies, and 5) programmatic assessment. This review advocates the adoption of the principles contained in the five core components of CBME, outlines the approach to implementation of CBVE based upon the five core components, and addresses the key differences between veterinary and medical education which may serve as challenges to ensuring fidelity of CBVE during implementation.

Capturing outcomes of competency-based medical education: The call and the challenge

There is an urgent need to capture the outcomes of the ongoing global implementation of competency-based medical education (CBME). However, the measurement of downstream outcomes following educational innovations, such as CBME is fraught with challenges stemming from the complexities of medical training, the breadth and variability of inputs, and the difficulties attributing outcomes to specific educational elements. In this article, we present a logic model for CBME to conceptualize an impact pathway relating to CBME and facilitate outcomes evaluation. We further identify six strategies to mitigate the challenges of outcomes measurement: (1) clearly identify the outcome of interest, (2) distinguish between outputs and outcomes, (3) carefully consider attribution versus contribution, (4) connect outcomes to the fidelity and integrity of implementation, (5) pay attention to unanticipated outcomes, and (6) embrace methodological pluralism. Embracing these challenges, we argue that careful and thoughtful evaluation strategies will move us forward in answering the all-important question: Are the desired outcomes of CBME being achieved?

Constructing a Validity Map for a Workplace-Based Assessment System: Cross-Walking Messick and Kane

PROBLEM

Health professions education has shifted to a competency-based paradigm in which many programs rely heavily on workplace-based assessment (WBA) to produce data for summative decisions about learners. However, WBAs are complex and require validity evidence beyond psychometric analysis. Here, the authors describe their use of a rhetorical argumentation process to develop a map of validity evidence for summative decisions in an entrustment-based WBA system.

APPROACH

To organize evidence, the authors cross-walked 2 contemporary validity frameworks, one that emphasizes sources of evidence (Messick) and another that stresses inferences in an argument (Kane). They constructed a validity map using 4 steps: (1) Asking critical questions about the stated interpretation and use, (2) Seeking validity evidence as a response, (3) Categorizing evidence using both Messick's and Kane's frameworks, and (4) Building a visual representation of the collected and organized evidence. The authors used an iterative approach, adding new critical questions and evidence over time.

OUTCOMES

The first map draft produced 25 boxes of evidence that included all 5 sources of evidence detailed by Messick and spread across all 4 inferences described by Kane. The rhetorical question-response process allowed for structured critical appraisal of the WBA system, leading to the identification of evidentiary gaps.

NEXT STEPS

Future map iterations will integrate evidence quality indicators and allow for deeper dives into the evidence. The authors intend to share their map with graduate medical education stakeholders (e.g., accreditors, institutional leaders, learners, patients) to understand if it adds value for evaluating their WBA programs' validity arguments.

Entrustment Unpacked: Aligning Purposes, Stakes, and Processes to Enhance Learner Assessment

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.

Clinical Documentation Practice: A Study of Doctors' Medical Documentary Compliance in Government Hospitals in Gampaha District, Sri Lanka

Doctors play a key role in health information system through clinical documentation. The study aimed to assess doctors' compliance with national medical documentation standards. The study was carried out in government hospitals having in-ward patient care facilities in Gampaha district, Sri Lanka. The doctors' knowledge and practices were assessed using a questionnaire. 500 Bed Head Tickets (BHTs) which are the medical records of inward patients, were audited in selected government hospitals in the same district using a check list to ascertain the doctors' compliance with standards in practice. Only 29.46% doctors were aware of the government circular on standards of medical record. Although 82.84%, 66.37% and 76.3% doctors knew that final diagnosis should be written according to International Classification of Diseases (ICD) 10, in block capitals and without any abbreviations, respectively. Only 7.61% BHTs were found to have fulfilled all standards. There were gaps in the knowledge of doctors regarding standards in clinical documentation practice. The awareness of and reference to published guidelines were not satisfactory. Poor transfer of knowledge into practice was evident by the results of BHT survey. As publishing guidelines or teaching alone may not improve the compliance of doctors with the standards in clinical documentation practice, more innovative strategies should be sought for.

Proposed definition of competencies for surgical neuro-oncology training

OBJECTIVE

The aim of this work is to define competencies and entrustable professional activities (EPAs) to be imparted within the framework of surgical neuro-oncological residency and fellowship training as well as the education of medical students. Improved and specific training in surgical neuro-oncology promotes neuro-oncological expertise, quality of surgical neuro-oncological treatment and may also contribute to further development of neuro-oncological techniques and treatment protocols. Specific curricula for a surgical neuro-oncologic education have not yet been established.

METHODS

We used a consensus-building approach to propose skills, competencies and EPAs to be imparted within the framework of surgical neuro-oncological training. We developed competencies and EPAs suitable for training in surgical neuro-oncology.

RESULT

In total, 70 competencies and 8 EPAs for training in surgical neuro-oncology were proposed. EPAs were defined for the management of the deteriorating patient, the management of patients with the diagnosis of a brain tumour, tumour-based resections, function-based surgical resections of brain tumours, the postoperative management of patients, the collaboration as a member of an interdisciplinary and/or -professional team and finally for the care of palliative and dying patients and their families.

CONCLUSIONS AND RELEVANCE

The present work should subsequently initiate a discussion about the proposed competencies and EPAs and, together with the following discussion, contribute to the creation of new training concepts in surgical neuro-oncology.

Are Clerks Proficient in the Basic Sciences? Assessment of Third-Year Medical Students' Basic Science Knowledge Prior to and at the Completion of Core Clerkship Rotations

Basic sciences are a cornerstone of undergraduate medical education (UME), yet research indicates that students' basic science knowledge is not well retained. Many UME curricula are increasing the integration between the basic and clinical sciences with the goal of enhancing students' knowledge levels; however, the impact of clerkship training on students' basic science knowledge remains inconclusive. Thus, using clerkship directors' expectations as framework, we aimed to assess third-year medical students' basic science knowledge during clerkship training and evaluate the influence of clerkship training on their basic science knowledge. Using concepts deemed necessary by clerkship directors, we created a basic science assessment for each clerkship rotation. Assessments were distributed to third-year medical students as a pre- and post-test to assess their basic science knowledge prior to and at the completion of each rotation. On average, students retained ≥ 60% of relevant basic science knowledge from pre-clerkship, and neither clerkship rotation order, nor the basic science discipline being assessed, impacted students' basic science knowledge levels. Post-test data revealed that students, on average, reinforced fundamental concepts during clerkship. Interestingly, even though lower-performing students demonstrated the greatest post-test improvement, they still left each rotation with knowledge deficits compared with their highest-performing peers, suggesting that the clinical experience of clerkship appears to be particularly beneficial for lower-performing students, in regard to enhancing their basic science knowledge. Overall, results indicate that earlier exposure to clinical learning in UME, along with integration of basic science education into clerkship, could promote students' basic science knowledge acquisition and retention.

Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis

Objective

Poor diet is a leading cause of death worldwide. Doctors are well placed to provide dietary advice, yet nutrition remains insufficiently integrated into medical education. Enforcement of curriculum or accreditation requirements such as nutrition requires relevant regulatory frameworks. The aim of this review was to identify nutrition content or requirements for nutrition education in accreditation standards or formal curriculum guidance for medical education internationally.

Design

Non-systematic comparative analysis.

Data sources

An internet search using the Google Search engine, the WHO Directory of Medical Schools and Foundation for Advancement of International Medical Education and Research Directory of Organizations that Recognise/Accredit Medical Schools was conducted through September 2020 to identify government and organisational reports as well as publications from regulatory and professional bodies relevant to medical education.

Eligibility criteria

Eligible publications included (A) accreditation standards, (B) competency standards or a framework, (C) curricula, and (D) assessment content.

Data extraction and synthesis

We stratified findings by country or region and both preregistration and postregistration education. Findings were synthesised based on the existence of nutrition content or requirements for nutrition education within systems used to guide medical education internationally.

Results

This review found that despite an emphasis on meeting the needs of the community and the demands of the labour market, only 44% of accreditation and curriculum guidance included nutrition. Nutrition remains inadequately represented in accreditation and curriculum guidance for medical education at all levels internationally. Accreditation standards provide a mandated framework for curricula and inclusion of nutrition in accreditation frameworks provides an incentive for the integration of nutrition into medical education.

Conclusions

This review is a call to action for the medical profession including government, health agencies and educational and accreditation entities. The inclusion of nutrition in medical education has appeared throughout medical education literature for more than five decades, yet without consensus standards there is little likelihood of uniform adoption.

What is the impact of the Rashomon approach in primary care education?: An educational case report of implementing dialogue and improvisation into medical education

BACKGROUND

The excessive sub-divided or concrete pre-determined objectives found in the technological approach in contemporary medical education curricula may hinder the students' spontaneous learning about diverse needs and values in care. However, medical professionals must learn the diversity for care or a variety of social factors of the patients influencing decision making in daily practice.

METHODS

We introduced a new method of curriculum development called the Rashomon approach. For testing the Rashomon approach, educational activities to teach the diversity in primary care were developed in four modules: 1) explication of the competency without specifying sub-objectives; 2) dialogue among multiple professional students; 3) visits and interviews of the patients; 4) dialogue with teachers' improvisation. The students' outcomes and responses were quantitatively and qualitatively analyzed.

RESULTS

A total of 135 medical students joined this study in 2017. The descriptive data suggested that the key concepts of diversity in primary care were fully recognized and that the pre-determined general goals were achieved. Scores on the understanding of social factors in medicine, respect for other professionals, professional identity, and satisfaction with the course were very high.

CONCLUSION

Instead of the technological approach, the Rashomon approach, in which only a general goal guides educational activities was used in this research. Improvisation and dialogue fit the approach and were potentially effective activities to learn the multifaceted practice of medicine. In an era of competency-based education, the Rashomon approach could be a very useful framework in primary care education.

Effectiveness of reflective learning in skill-based teaching among postgraduate anesthesia students: An outcome-based study using video annotation tool

BACKGROUND

Medical education all over the world is undergoing paradigm shift. Video recording of student's performance and self-annotation are emerging as valuable tools for self-directed learning among students. Study was conducted to find the effectiveness of video annotation tool in reflective learning. The learning outcome was to find whether the video annotation is helping in critical reflection and improving the perception of students on guideline compliance while learning the technique of epidural insertion.

METHODS

In phase 1; following pretest, the students were made to observe three epidural insertions and perform one epidural insertion. In phase 2; following posttest, two faculty members analyzed the depth of reflection using the Reflection Rubric. Students perception was recorded using the Reflective practice survey.

RESULTS

The average score of students after pretest was 76%. The posttest score was 84% (p value 0.003). In depth analysis using the reflection rubric we found 52.38% of the total reflections had a score of two, showing they were at introspection level only. 25.71% of reflections were having score of one, showing that they were just habitual answers. Only 21.9% of the total reflections had score of three; and none of them were critically reflecting. All the students (18/18) agreed that recording the session was meaningful.

CONCLUSION

The art of critical reflection is learnt by relentless effort. Yet it helps the students to reflect on the whole process introspecting and understanding what went wrong. Video annotation turns out to be a valuable tool in reflective learning.

Design, Implementation and Evaluation of a Distance Learning Framework to Expedite Medical Education during COVID-19 pandemic: A Proof-of-Concept Study

BACKGROUND

The COVID-19 pandemic has forced medical schools to suspend on-campus live-sessions and shift to distance-learning (DL). This precipitous shift presented medical educators with a challenge, 'to create a "simulacrum" of the learning environment that students experience in classroom, in DL'. This requires the design of an adaptable and versatile DL-framework bearing in mind the theoretical underpinnings associated with DL. Additionally, effectiveness of such a DL-framework in content-delivery followed by its evaluation at the user-level, and in cognitive development needs to be pursued such that medical educators can be convinced to effectively adopt the framework in a competency-based medical programme.

MAIN

In this study, we define a DL-framework that provides a 'simulacrum' of classroom experience. The framework's blueprint was designed amalgamating principles of: Garrison's community inquiry, Siemens' connectivism and Harasim's online-collaborative-learning; and improved using Anderson's DL-model. Effectiveness of the DL-framework in course delivery was demonstrated using the exemplar of fundamentals in epidemiology and biostatistics (FEB) course during COVID-19 lockdown. Virtual live-sessions integrated in the framework employed a blended-approach informed by instructional-design strategies of Gagne and Peyton. The efficiency of the framework was evaluated using first 2 levels of Kirkpatrick's framework. Of 60 students, 51 (85%) responded to the survey assessing perception towards DL (Kirkpatrick's Level 1). The survey-items, validated using exploratory factor analysis, were classified into 4-categories: computer expertise; DL-flexibility; DL-usefulness; and DL-satisfaction. The overall perception for the 4 categories, highlighted respondents' overall satisfaction with the framework. Scores for specific survey-items attested that the framework promoted collaborative-learning and student-autonomy. For, Kirkpatrick's Level 2 that is, cognitive-development, performance in FEB's summative-assessment of students experiencing DL was compared with students taught using traditional methods. Similar, mean-scores for both groups indicated that shift to DL didn't have an adverse effect on students' learning.

CONCLUSION

In conclusion, we present here the design, implementation and evaluation of a DL-framework, which is an efficient pedagogical approach, pertinent for medical schools to adopt (elaborated using Bourdieu's Theory of Practice) to address students' learning trajectories during unprecedented times such as that during the COVID-19 pandemia.

Collaborative Development of a Shared Framework for Competency-Based Veterinary Education

Competency-based medical education is an educational innovation implemented in health professions worldwide as a means to ensure graduates meet patient and societal needs. The focus on student-centered education and programmatic outcomes offers a series of benefits to learners, institutions and society. However, efforts to establish a shared, comprehensive competency-based framework in veterinary education have lagged. This article reports on the development and outcome of a competency-based veterinary education (CBVE) framework created through multi-institutional collaboration with international input from veterinary educators and veterinary educational leaders. The CBVE Framework is designed to reflect the competencies expected of new graduates from member institutions of the Association of American Veterinary Medical Colleges (AAVMC). The CBVE Framework consists of nine domains of competence and 32 competencies, each supplemented with illustrative sub-competencies to guide veterinary schools in implementing competency-based education in their local context. The nine domains of competence are: clinical reasoning and decision-making; individual animal care and management; animal population care and management; public health; communication; collaboration; professionalism and professional identity; financial and practice management; and scholarship. Developed through diverse input to facilitate broad adoption, the CBVE Framework provides the foundation for competency-based curricula and outcomes assessment in veterinary education internationally. We believe that other groups seeking to design a collective product for broad adoption might find useful the methods used to develop the CBVE Framework, including establishing expertise diversity within a small-to-medium size working group, soliciting progressive input and feedback from stakeholders, and engaging in consensus building and critical reflection throughout the development process.

Effective accreditation in postgraduate medical education: from process to outcomes and back

BACKGROUND

The accreditation of medical educational programs is thought to be important in supporting program improvement, ensuring the quality of the education, and promoting diversity, equity, and population health. It has long been recognized that accreditation systems will need to shift their focus from processes to outcomes, particularly those related to the end goals of medical education: the creation of broadly competent, confident professionals and the improvement of health for individuals and populations. An international group of experts in accreditation convened in 2013 to discuss this shift.

MAIN TEXT

Participants unequivocally supported the inclusion of more outcomes-based criteria in medical education accreditation, specifically those related to the societal accountability of the institutions in which the education occurs. Meaningful and feasible outcome metrics, however, are hard to identify. They are regionally variable, often temporally remote from the educational program, difficult to measure, and susceptible to confounding factors. The group identified the importance of health outcomes of the clinical milieu in which education takes place in influencing outcomes of its graduates. The ability to link clinical data with individual practice over time is becoming feasible with large repositories of assessment data linked to patient outcomes. This was seen as a key opportunity to provide more continuous oversight and monitoring of program impact. The discussants identified several risks that might arise should outcomes measures completely replace process issues. Some outcomes can be measured only by proxy process elements, and some learner experience issues may best be measured by such process elements: in brief, the "how" still matters.

CONCLUSIONS

Accrediting bodies are beginning to view the use of practice outcome measures as an important step toward better continuous educational quality improvement. The use of outcomes will present challenges in data collection, aggregation, and interpretation. Large datasets that capture clinical outcomes, experience of care, and health system performance may enable the assessment of multiple dimensions of program quality, assure the public that the social contract is being upheld, and allow identification of exemplary programs such that all may improve. There remains a need to retain some focus on process, particularly those related to the learner experience.

National Survey on Canadian Undergraduate Medical Programs: The Decline of the Anatomical Sciences in Canadian Medical Education

The anatomical sciences have always been regarded as an essential component of medical education. In Canada, the methodology and time dedicated to anatomy teaching are currently unknown. Two surveys were administered to course directors and discipline leaders to gain a comprehensive view of anatomical education in Canadian medical schools. Participants were queried about contact hours (classroom and laboratory), content delivery and assessment methods for gross anatomy, histology, and embryology. Twelve schools responded to both surveys, for an overall response rate of 64%. Overall, Canadian medical students spend 92.8 (± 45.4) hours (mean ± SD) studying gross anatomy, 25.2 (± 21.0) hours for histology, and 7.4 (± 4.3) hours for embryology. Gross anatomy contact hours statistically significantly exceeded those for histology and embryology. Results show that most content is delivered in the first year of medical school, as anatomy is a foundational building block for upper-year courses. Laboratory contact time for gross anatomy was 56.8 (± 30.7) hours, histology was 11.4 (± 16.2) hours, and embryology was 0.25 (± 0.6) hours. Additionally, 42% of programs predominantly used instructor/technician-made prosections, another 33% used a mix of dissection and prosections and 25% have their students complete cadaveric dissections. Teaching is either completely or partially integrated into all Canadian medical curricula. This integration trend in Canada parallels those of other medical schools around the world where programs have begun to decrease contact time in anatomy and increase integration of the anatomical sciences into other courses. Compared to published American data, Canadian schools offer less contact time. The reason for this gap is unknown. Further investigation is required to determine if the amount of anatomical science education within medical school affects students' performance in clerkship, residency and beyond.

How accurate are we? A comparison of resident and staff physician billing knowledge and exposure to billing education during residency training

Background

Practice management is an overlooked and undertaught subject in medical education. Many physicians feel that their exposure to billing education during residency training was inadequate. The purpose of this study was to compare resident and staff physicians in terms of their billing knowledge and exposure to billing education during residency training.

Methods

Senior residents and staff physicians completed a scenario-based clinical billing assessment. Posttest surveys were completed to determine exposure to practice management and billing education during training.

Results

A total of 16 resident physicians and 17 staff physicians completed the billing assessment. Overall, the billing accuracy of respondents was poor. Staff physicians had a greater percentage of correct billing codes (55.3% v. 37.5%, p < 0.001) and underbilled codes (6.2% v. 3.4%, p = 0.009), with fewer missed billing codes (38.5% v. 59.1%, p < 0.001), compared with resident physicians. The percentage value of correct billings was significantly higher for staff physicians (71.5% v. 56.8%, p = 0.01). In the posttest survey, 100.0% of residents and 79.0% of staff physicians desired more billing education during training.

Conclusion

In general, staff physicians billed more accurately than resident physicians, but even experienced staff physicians missed a substantial amount of potential revenue because of billing errors and omissions. The majority of the residents and staff physicians who participated in our study felt that current billing education is both insufficient and ineffective. Incorporating practice management and billing education into residency training is critical to ensure that the next generation of medical trainees possess the financial competence to required to manage a successful medical practice.

Implicit expression of uncertainty - suggestion of an empirically derived framework

BACKGROUND

Uncertainty occurs in physicians' daily work in almost every clinical context and is also present in the clinical reasoning process. The way physicians communicate uncertainty in their thinking process during handoffs is crucial for patient safety because uncertainty has diverse effects on individuals involved in patient care. Dealing with uncertainty and expressing uncertainty are important processes in the development of professional identity of undergraduate medical students. Many studies focused on how to deal with uncertainty and whether uncertainty is explicitly expressed. Hardly any research has been done regarding implicit expression of uncertainty. Therefore, we studied the ways in which medical students in the role of beginning residents implicitly express uncertainty during simulated handoffs.

METHODS

Sixty-seven advanced undergraduate medical students participated in a simulated first day of residency including a consultation hour, a patient management phase with interprofessional interaction, and a patient handoff. We transcribed the videographed handoffs verbatim and extracted language with respect to expression of uncertainty using a grounded theory approach. Text sequences expressing patient related information were analyzed and coded with respect to language aspects which implicitly modified plain information with respect to increasing or decreasing uncertainty. Concepts and categories were developed and discussed until saturation of all aspects was reached.

RESULTS

We discovered a framework of implicit expressions of uncertainty regarding diagnostic and treatment-related decisions within four categories: "Statement", "Assessment", "Consideration", and "Implication". Each category was related to either the subcategory "Actions" or "Results" within the diagnostic or therapeutic decisions. Within each category and subcategory, we found a subset of expressions, which implicitly attenuated or strengthened plain information thereby increasing uncertainty or certainty, respectively. Language that implicitly attenuated plain information belonged to the categories questionable, incomplete, alterable, and unreliable while we could ascribe implicit strengtheners to the categories assertive, adequate, focused, and reliable.

CONCLUSIONS

Our suggested framework of implicit expression of uncertainty may help to raise the awareness for expression of uncertainty in the clinical reasoning process and provide support for making uncertainty explicit in the teaching process. This may lead to more transparent communication processes among health care professionals and eventually to improved patient safety.

From prescription to guidance: a European framework for generic competencies

In postgraduate medical education, required competencies are described in detail in existing competency frameworks. This study proposes an alternative strategy for competency-based medical education design, which is supported by change management theories. We demonstrate the value of allowing room for re-invention and creative adaptation of innovations. This new strategy was explored for the development of a new generic competency framework for a harmonised European curriculum in Obstetrics and Gynaecology. The generic competency framework was developed through action research. Data were collected by four European stakeholder groups (patients, nurses, midwives and hospital boards), using a variety of methods. Subsequently, the data were analysed further in consensus discussions with European specialists and trainees in Obstetrics and Gynaecology. These discussions ensured that the framework provides guidance, is specialty-specific, and that implementation in all European countries could be feasible. The presented generic competency framework identifies four domains: 'Patient-centred care', 'Teamwork', 'System-based practice' and 'Personal and professional development'. For each of these four domains, guiding competencies were defined. The new generic competency framework is supported by European specialists and trainees in Obstetrics and Gynaecology, as well as by their European stakeholders. According to change management theories, it seems vital to allow room for re-invention and creative adaptation of the competency framework by medical professionals. Therefore, the generic competency framework offers guidance rather than prescription. The presented strategy for competency framework development offers leads for implementation of competency-based medical education as well as for development of innovations in postgraduate medical education in general.

Artificial intelligence outperforms human students in conducting neurosurgical audits

OBJECTIVES

Neurosurgical audits are an important part of improving the safety, efficiency and quality of care but require considerable resources, time, and funding. To that end, the advent of the Artificial Intelligence-based algorithms offered a novel, more economically viable solution. The aim of the study was to evaluate whether the algorithm can indeed outperform humans in that task.

PATIENTS & METHODS

Forty-six human students were invited to inspect the clinical notes of 45 medical outliers on a neurosurgical ward. The aim of the task was to produce a report containing a quantitative analysis of the scale of the problem (e.g. time to discharge) and a qualitative list of suggestions on how to improve the patient flow, quality of care, and healthcare costs. The Artificial Intelligence-based Frideswide algorithm (FwA) was used to analyse the same dataset.

RESULTS

The FwA produced 44 recommendations whilst human students reported an average of 3.89. The mean time to deliver the final report was 5.80 s for the FwA and 10.21 days for humans. The mean relative error for factual inaccuracy for humans was 14.75 % for total waiting times and 81.06 % for times between investigations. The report produced by the FwA was entirely factually correct. 13 out of 46 students submitted an unfinished audit, 3 out of 46 made an overdue submission. Thematic analysis revealed numerous internal contradictions of the recommendations given by human students.

CONCLUSION

The AI-based algorithm can produce significantly more recommendations in shorter time. The audits conducted by the AI are more factually accurate (0 % error rate) and logically consistent (no thematic contradictions). This study shows that the algorithm can produce reliable neurosurgical audits for a fraction of the resources required to conduct it by human means.

Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities

IMPORTANCE

Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence.

OBJECTIVE

To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018.

INTERVENTIONS

Longitudinal, prospective assessment using EPAs.

MAIN OUTCOMES AND MEASURES

Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA.

RESULTS

Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician).

CONCLUSIONS AND RELEVANCE

This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

Contextual Analysis of Stakeholder Opinion on Management and Leadership Competencies for Undergraduate Medical Education: Informing Course Design

BACKGROUND

The study aimed to conduct a contextual analysis of interviews intended to assist with the future design of a feasible and relevant leadership and management course for undergraduate medical students at King Abdulaziz University (KAU), Saudi Arabia.

METHODS

This was a cross-sectional study conducted at King Abdulaziz University (KAU), Saudi Arabia, during 2019. An exploratory qualitative approach, utilizing systematic content analysis, was used. Data were collected using semi-structured interviews that were conducted with 10 leaders who were stakeholders at KAU, health service providers at KAU hospital, and stakeholders in the Ministry of Health.

RESULTS

This study revealed critical findings that highlighted the areas in which KAU could instill better and adequate leadership and management skills in their undergraduate medical students. Multiple core categories for a leadership and management curriculum emerged with many interrelated themes. Most participants mentioned that leadership can be taught and that early exposure is beneficial for developing skills. Additionally, they stated that leaders should have a vision and the ability to articulate that vision.

CONCLUSIONS

Different implementation challenges were described in relation to the availability of human resources, the current short supply of suitable teachers, and program design. Teaching methods recommended included simulations, lectures, and a project-based approach. Assessment methods that were recommended included objective structured clinical examination (OSCE), formative and summative assessments, self-assessments, and portfolios.

Identifying the learning objectives of clinical clerkship in community health in Japan: Focus group

Background

The value of medical education in the community has been increasingly and globally recognized. In 2015, the World Federation for Medical Education emphasized the importance of medical education in various settings in their standard. Similarly, in Japan, the Model Core Curriculum for Medical Education in Japan (MCCMEJ) is revised in 2016. However, both the learning objectives of such clerkships and their concrete strategies in Japan are not clearly established. In this study, the authors identified the learning objectives of clinical clerkship in community health reflecting the perspectives of medical professionals and community inhabitants.

Methods

They held six focus groups that included physicians, other medical professionals, and inhabitants (n = 35) who were involved in a clinical clerkship in community health at three prefectures in Japan from 2017 to 2018. Further, they recorded, transcribed, and thematically analyzed the discussion using MCCMEJ as conceptual frameworks.

Results

The learning objectives comprised of 13 domains. The following four domains were not found in "Basic Qualities and Capacities for Physicians" in MCCMEJ: "future-oriented systematic view," "organic integration of knowledge/skill," "understanding of the community," and "awareness as an individual physician."

Conclusion

With the community inhabitants' participation, the study results reflect the community needs in Japan. The authors hope that the outcome of this study will be useful to further improve clinical clerkship in community health.

Developing a competency framework for Health Professions Education at doctoral level: The first step toward a competency based education

Introduction: The aim of this study was to develop the competency framework for Doctoral graduates in Health Professions Education, which is the first step in implementing an outcome-based curriculum. Method: The present study conducted in three phases. First, viewpoints of 100 stakeholders, including students, graduates, faculty members, and educational managers were explored by using Nominal Group technique, survey, and telephone interviews. The extracted codes classified in subcategories and categories through an inductive content analysis approach. In phase two, the findings converted to competency components, sub-domains and competency domains in working groups. Finally, the content validity of the developed components evaluated through qualitative and quantitative approaches. Results: 535 codes, 12 sub-categories, and 7 categories extracted from stakeholders' viewpoints, which were refined to 65 competency components, 12 sub-domains and 7 competency domains in working groups. The final competency framework includes 54 competency components in seven competency domains of a "professional expert", "research and scholarship", "teaching", "interdisciplinary collaboration", "leadership and management", "professionalism", "personal and professional development". Conclusion: Competency framework is essential for the development of a comprehensive and integrated curriculum. It would be possible to implement a competency-based curriculum in the Doctoral program of Health Professions Education by developing the competency framework.